 Welcome to the latest installment of the Let's Talk series presented by the Bedford Playhouse. My name is Dan. I am the Director of Development and Programming. I'm very glad to see all of you taking a few minutes out of your busy schedules to join us for what I'm sure is going to be a very fascinating conversation. A couple of quick things before we get started. I want to just point out that at any time during the presentation and conversation if you would like to ask a question that will be addressed in the Q&A portion of the evening, you all should have a Q&A button which is usually at the bottom of your screen if you are on a laptop or PC. I think if you're on an iPad or an iPhone it's towards the top of your screen. We ask that you please post any questions, comments, thoughts you may want to share in the Q&A forum and not the chat forum. We want to make sure that we get as many as we can and it gets a little bit confusing to go back and forth so please use the Q&A button. Also I would like to mention that we are recording tonight's conversation so everyone who registered will receive an email with a link to the recording. If there's anyone who couldn't be with us tonight that you know who you think would benefit from seeing this we'll be sending you that link that you can share. Lastly I just want to say if you like this type of program and you find it helpful or useful to you and you'd like to see us continue to do more of it please consider making a donation to the Bedford Playhouse. Any amount is appreciated it helps us through this time when our doors are shut thanks to COVID. Hopefully we will be able to slowly move our way back to normal operations through the course of this year but in the meantime we are still closed and we are presenting many programs virtually. You can go to our website which is bedfordplayhouse.org and you also can see some of the other programs other great programs that we have coming up over the next several weeks. So that being said I'd like to jump right in and introduce to you the first speaker of the evening Stephanie Marquisano. Stephanie's 19 year old son died by accidental overdose in 2013 and when she founded the Harris project to advance prevention programming and advocate for the implementation of integrated treatment to improve outcomes for teens and young adults with co-occurring disorders. The Harris project has become a leading voice in promoting an understanding of COD and benefits of system transformation and Stephanie brings her perspective out to this critical topic serving on a broad range of New York state mid Hudson region and Western County committees she received her JD from the NYU school of law and as a former Ardsley New York school board member and PTA president please welcome Stephanie Marquisano. Hi Stephanie. Thank you so much Dan and I wish I could actually see and feel everybody who's out there. I think one of the things that I miss in this webinar format is the ability to kind of connect and see you but we're going to do the best we can and hopefully when it's time to chat you know you'll be able to engage a little bit more. So yes I am Stephanie Marquisano founder and president of the Harris project. For some of you you may be thinking you know what is co-occurring disorders why should I care about it and how did this all happen so for me my son had an anxiety disorder he had ADHD he turned to substances first marijuana to self-medicate and then fast forward to 11th grade in high school and that is when he found his way to opioids at a party in my community and by mid-year senior year he went to his first inpatient rehabilitation program. It was the first time we ever heard of co-occurring disorders they said he has co-occurring disorders a young person with a mental health disorder who is self-medicating that's what it is and we thought well okay it has a name they say they treat it everything will be okay. What we found in the year and a half before he died going to two outpatient treatment programs for inpatient treatment programs no matter what they said they didn't actually treat co-occurring disorders they led with the substance use piece and they never addressed the mental health piece. When a 19 year old dies in a small community like Ardsley everybody wants to know where do we make donations what do we do how do we support you and my daughter was a senior in high school she was a week away from her early decision application to Syracuse University she wanted to be a social worker she now has her master's in social work works at Mercy College with their student athletes but at that moment in time I thought don't make donations just anywhere they said he had something I need to understand what went wrong from a prevention standpoint I was a PTA president we used to bring the programs in like what did I do wrong and then on the treatment side where could things have gone differently so at my kitchen table and I do these presentations to like thousand students in an auditorium and I unpack all of this with a PowerPoint presentation I sat at my kitchen table and I figured out what I thought went wrong from soup to nuts so I started you know presenting and talking about it and I know um Commissioner Michael Orth is on this zoom right now um he's the commissioner for the Department of Community Mental Health and when we met for the very first time and I shared kind of my vision for co-occurring disorders and what we could do we wrote two things on a piece of paper youth engagement and moving the mountain on treatment and that's what we set out to do so what happened we created CODA co-occurring disorders awareness designed to empower young people you know you hear the message like mental health matters you learn through all these programs you know just say no how do you end up in the narrative anyway like mental health matters why because we don't take care of our mental health we'll do things like self-medicate we'll do things like non-suicidal self-injury we will navigate to ways to cope and manage that aren't healthy so if we empower young people to truly understand the relationship that's the home run that's the prevention that's the way to connect to resources and support each other early on so CODA took off you know we have a youth summit that's supported by the county we do awareness games and you know we've got our logo and and it's on helmets and it's on sticks and there are field announcements and we're talking co-occurring disorders we celebrate co-occurring disorders weeks I mean I remember everybody's like well how did we pick April for co-occurring disorders awareness weeks Harris's birthday was April 8 and I thought if this hits I'm always going to have something positive and supportive to do on his birthday and so it started as a week then it became two weeks then it became a month and so all these activities really started building momentum we created hashtags through a youth focus group and and the momentum really built the challenge was that the treatment part still wasn't where we needed it to be so I kind of would always go kind of where the energy was like if prevention was going well then maybe the treatment piece slowed down but what could we do I became the youth advocate for the New York state mid Hudson regional planning consortium it's a place that was designed for Medicaid redesign I started talking about integrated treatment I was working with an international systems change expert our mid Hudson region brought him in within seven months so now our seven counties are all doing work to say how do we bring our mental health and substance use providers together and I know Vanessa is going to ask a lot of questions later part of the problem is the way that the system is set up it's set up like in silos they're separate their their funds don't really intermingle so we work really hard in advocacy to kind of shift that dynamic but that still wasn't enough because young people were still entering the narrative and still needed the right kind of treatment I heard Dr. Paula riggs speak last year in November at a conference and I met with Michael and you know back then we actually had like a conference call nobody was zooming and we we had a conference call with Paula riggs and I said you know you've created this integrated treatment model for teens and young adults with co-occurring disorders if I could ever afford you we're going to do a project here and during COVID we got funded WMC health put out a grant for promising practices and they knew about my work through the mid Hudson regional planning consortium and family services of westchester partnered with us and now we have six agencies 22 clinicians right here in westchester county doing an evidence-based treatment model and now you know I was just on a on a zoom with with commissioner or we're looking at getting federally funded to really expand the project even bigger so what I guess I want you to know as an audience my story is tragic I don't ever want this to happen to another family but I firmly believe that there is hope in sort of the the youth empowerment piece the fact that our school districts are so incredibly invested in the work the fact that even nationally I've created curriculum for the national interest scholastic athletic administrators association and it's not just about mental health and student athletes it includes substance use it includes co-occurring disorders the more we talk about this the easier it is for young people to self identify to talk about how their friends are doing to bring people to get that help and support that they might have not known that they even needed and so when we look at what this event was titled you know maybe it's not just experimentation that's really the heart and soul of this because you know there was a time when you didn't go to cocktail party and hold a drink and you weren't going to a baseball game and holding a beer like we and my generation is the one that said you know we need to do something we need to drink something we need to take something in order to feel comfortable in social situations for our youth what I try to impart with them is do I want you all to be abstinent 100 percent that is my goal but if you're not or you're doing things what if you stopped and thought well why am I doing this am I doing this because I don't feel comfortable in my own skin am I doing this because I want to be more sexually promiscuous and I need to like let go and not be in control if you can stop and think about the why that is the first step in identifying if there might be a problem and so really allowing them to to take the information and apply it to their own lives and then you know that's part of our coda connects like that's our first hashtag hashtag coda connect everyone has the power to connect and support one another like I'm at a party my friend is drinking they're drinking to black out and I'm worried am I going to laugh and kind of take pictures and post it on social media or am I going to say you know I've noticed that I'm concerned when I see you and then the other hashtag we have hashtag be the link who would I link to if I was concerned about myself or a friend is it a parent is it a coach is it a teacher at school and I have to say during this time you know we're all living in this strange space with coded it's really hard you know teachers aren't seeing their students the same way you know sometimes it's coaches which is why I do so many trainings to get as many eyes on our young people that's why I do so many student presentations even via zoom because the chats and the conversations and the awareness that comes is so critical during this really weird space and time and then for some of you you may have children who are more comfortable right now like it's almost a relief like I often think about you know what would Harris have been like during this COVID time would have felt like he was off America rounds and not having to kind of front and maybe this would have been relaxing but now thinking about reemerging there might be some problems so I know like I'm kind of running out of my time and I could talk about this you know all night but I know that I need to turn it over to Dr. Avery now so I'm going to return it back to Dan and I'm all you know we're going to have a big Q&A after so I'm looking forward to seeing you then so Dan thanks so much I'm going to shut my screen and my mic thanks very much Stephanie and as Stephanie alluded I'd like to now introduce the our second speaker of the evening Dr. Jonathan Avery is the director of addiction psychiatry and an associate professor of clinical psychiatry at Wild Cornell Medical College and New York Presbyterian Hospital. Dr. Avery's primary academic focus has been to examine and help develop interventions to improve clinicians attitudes towards patients with substance use disorders. He's also focused on educating all physicians on how to treat individuals with co-occurring substance use disorders and mental illness. Please welcome Dr. Jonathan Avery. Thank you Dan for having me and thank you Stephanie for for sharing your story and thank you all for joining today you know I think we need to be talking as families as communities as often as possible without co-occurring disorders about how mental illness and substance use often occur together and all that we can do about it and I thought you know as I was becoming an addiction psychiatrist that everyone would share my enthusiasm for this space you know that as a country we would see that tens of thousands of people are passing away due to substance use disorders that it's impacting you know a third to two-thirds of it of us have it in our primary family no one's immune but one thing I discovered as I was becoming an addiction psychiatrist is that nobody shared my enthusiasm for working with folks with substance use disorder and that led that I found that very confusing and that led to my primary research focus which has been to understand why there's so much stigma as it relates to addiction and co-occurring disorders and what my research has shown is that our attitudes in society even in the places that should be the safest like among medical professionals lawyers and our families and schools our attitudes towards folks who use substances and folks who have co-occurring disorders are worse than towards any other group of people um any other medical or psychiatric condition and it's certainly impacted by race and all sorts of factors and and I think a lot of this stigma is a result of people not understanding co-occurring disorders not understanding why people use substances not understanding the degree to which people have mental health struggles and and so that's why I think it's so great that we're all here thinking about this together and just to sort of underscore and highlight some of the things that Stephanie was mentioning co-occurring disorders is when one has mental illness like anxiety and depression or bipolar disorder and then one has a substance use disorder that is you're misusing substances from alcohol cocaine opiates and the estimated numbers of people in the united states with those co-occurring disorders is about 8 to 15 million and about 22 million people around the united states struggle with substance use disorders and the time that these conditions emerge and they often emerge together is in adolescence and a lot of the risk factors include genetics trauma difficult early experiences but even without that nobody is immune um and sometimes substance use as Stephanie was mentioning develops because one's medicating the difficult psychiatric states sometimes one gets exposed to a substance and that sort of elicits or causes an underlying psychiatric condition to merge but regardless we tend to see them both emerge together as people progress through adolescence and by the age 22 25 most of the folks who will develop a substance use disorder as as high as 90 percent have developed it by that point and so often these these talks and as Stephanie is doing in her amazing work i did a panel with Stephanie by the way in 2017 and she was updating me this week on all the work she's done in the last four years it's truly remarkable and and the spirit of it is right on and now we have to be talking to families we have to be talking in the schools and we have to be informing everyone about co-occurring disorders and getting this conversation going and so what's the recommendation giving this is how co-occurring disorders happens the recommendation is that as families we should start talking to our kids about it beginning at age nine um and then to highlight early to them that this is in something important for us as a family and around the same time we'd encourage schools and and other organizations that people are part of to start having conversations about it like we're having here um and that includes examining our own substance use as parents and family members being open about family and and everyone struggles with mental illness if there was cancer in the family if there was any other medical condition we wouldn't ignore it the way we have historically ignored mental illness and substance use um and i think in terms of prevention that's one of the keys is to talk and talk about it and and make it uh not stigmatized and and so people can learn the lesson like Stephanie was saying that it's okay to be them and if it's struggling with substances if it's having mental health struggles that that's okay we can work on this together and it's not something we have to hide or be ashamed about um and i think what's happened because of the stigma and because of how substance use and mental health has been situated is that very few people get care and get good care so of those numbers i mentioned to you about 22 million with substance use you know 10 million or so with co-occurring disorders less than 10 get treatment for both co-occurring mental illness and substance use 50 never get any treatment at all some might get some mental health treatment here and there or get some substance use treatment here and there but it's a real problem with the way our treatments work and and that we're not offering enough co-occurring disorders that's why it's so amazing what Stephanie's doing in westchester and increasing all the access and it's our hope for all of us in all communities that we have increased access to treatment for co-occurring disorders and so if the stigma is down and we have these low barriers to treatment it's our hope that people will take will access care the important care that's needed for co-occurring disorders and you know historically people thought that maybe before treating mental illness you had to treat the substance use or before treating the substance use you had to treat the mental illness and people often talked about the stepwise treatment to co-occurring disorders but we thought we've learned over time and and i wrote a book on this for the American psychiatric association we've learned that the stepwise treatment is wrong that the best treatment is to address everything at the same time that is you can't address the substance use if you're not addressing the underlying anxiety you can't address the anxiety unless you're addressing the problematic drinking and so our treatments these days focus on addressing everything at the same time getting people to write therapy the medications to address their mental health issues at the same time giving them the needed tools to address the substance issues as they come along and i think this approach of being open about it of treating all the conditions allow will hopefully allow more people to get into recovery and the the thing that sometimes lost and i think this is changing is that many people do get into recovery and there's a lot of hope and so while there's 22 million people struggling with substance use disorders now i think the number of people in recovery in the united states is something like 23 or 24 million and the odds are that that for folks who are struggling through their teens that they'll make it into recovery one day but we certainly need to do more we need to take Stephanie's lead and the lead of many others to to sort of do more to address it in our communities and you know certainly in the medical community we're working with pediatricians and internists and psychiatrists to be more aware of co-occurring disorders and how to treat them in the best way and i too like Stephanie could talk about this for hours and sometimes i do but i will pause because i know there's a lot of questions and invite Dan back to introduce i think our moderator Vanessa and then we'll we'll have you to take questions indeed okay thank you dr. avie so yes let's invite Stephanie back and i want to quickly introduce everyone to our moderator for the evening uh Vanessa Smith hi Vanessa hello it's it's your show i'm going back into lurk in the background great we already have a lot of questions and that was fantastic thank you dan um one of the questions is that lots of places list themselves as as places to have co-occurring disorders treated but very few people have found some of the people in our audience have found that very few places do both so what do you do what do parents do what do people seeking help do so i think we're in a really positive space right now and i will say that for all of my initial years of doing this work and helping families navigate to resources i literally created a list like how to vet a program you know the kind of questions that you would need to ask about what they truly do to manage both you know how much time if you were in a residential program would you see the psychologist the psychiatrist what's their position on medication and all of those other things but now we're in this unique space within compass so with our 22 clinicians and our six agencies the goal when we put out the loi was to not get providers that only served a certain demographic population so we have providers now who serve people who have Medicaid people who are under insured private insurance and private pay and it's it's a manualized once a week individual treatment and it's designed as a multiple ways it's designed to be the first stop if you've got early use it's designed instead of a residential program because it often works better than a residential program it's also designed to support young people who may be coming home from a wilderness program or you know some other place the challenge is you know and I always say you know we do the next great thing and then like okay we're done like we've got in compass we're good what we've already found and we rolled this out in November so the trainings happened and we've got everybody on board and they do clinical consultations like this is this is a project done with fidelity so they consult with the developer of the program every other week and everybody's very engaged what's my problem right now the parents and the loved ones because we are indoctrinated as Dr. Avery knows into this belief that people who are using substances are bad like they're doing the wrong thing so let's write a contract let's be punitive and kick them out if they're not abstinent but everything about in compass is rooted in motivational interviewing um motivational enhancement therapy cognitive behavioral therapy really building positive supports and if you've got that dynamic where you're getting in trouble for everything that goes wrong and you're feeling like you're about to get kicked out of the house that's not so therapeutically beneficial so now we're looking at bringing in craft which is a community um it's an evidence-based program to support the family so that the family learns ways to support that young person so it's kind of a comprehensive opportunity yeah and I'll add to that I mean some great points in that you know people misusing substances aren't aren't bad people doing bad things but sick people becoming well and the whole emphasis of co-occurring disorders are that these are diseases that deserve our empathy and treatment and we should be treating them all and the reality and it's a great question is that so many rehabs around the country are terrible just to like put that out there they're not offering evidence-based care they're not addressing co-occurring disorders and unfortunately in this space because there's such a need there's a lot of people that are putting out all sorts of problematic treatments and and so you want to look for those things that Stephanie are mentioning that we have the sort of robust psychiatric and and psychotherapy care along with the proper treatments for substance use disorder and a menu of options for each of them you know because not every therapy is good for every person not every medication and then certainly when opiate use disorder is involved in the world of addiction we think of all substances on one hand and opiate use disorder on the other hand for opiate use disorder we really think you need to be on medications like buprenorphine or methadone or vivitrol in order to have the best outcomes and so a lot of facilities don't offer this medical evidence-based care for opiate use disorder or provide sort of naloxone rescue kits which are basically nasal sprays that help if people are in overdose states and so we want treatment programs that are doing all the evidence-based providing the right meds the right psychiatric care and unfortunately a lot orange which is you know why it's so great the work that that Stephanie's doing in her community and that it's it's providing all these things well it's almost like people need to need references and advisors or consultants to know where to go and to find the right fit by the way could you hold that up again sure I'll show these kits we do these trainings at the hospital they're available all throughout New York state and basically it provides a Narcan which is a nasal spray and that if someone has overdosed the idea is that you tilt the head back and spray it up the nose and it can rescue someone and the scary thing about substance misuse these days is that there's fentanyl contaminating a lot of substances of abuse and so even people not seeking out opiates are accidentally overdosing and so we're encouraging all families actually to to have Narcan available and the Surgeon General said that all families should as well not just us and that it's something important to keep around that's great let's let's add a list when we put this on on YouTube let's add a list of some of these some of these things another question came in and now this is from someone who has a daughter with co-occurring he didn't have the right kind of guidance so her question is should pediatricians take a family history about substance abuse and mental health issues and should they inform parents what to look for when there is a risk in other words it's a helpful situation what do you think about that so I actually just did a presentation last week for Boston Children's um through that they have a behavioral health component and many of the pediatric practices have an embedded social worker and so I was doing kind of an in-service to talk about our co-occurring work and they often do what I would call the traditional mental health screens but they're really disinclined and almost afraid to do the substance use screen so there's something called the s2bi which is literally a minute to a minute and a half that just covers the basics on substances and kind of causes that kind of break off point between congratulating the young person for not really using substances and saying you know this is great and talking about the risks of medic self-medication if you've got a mental health disorder and then that break up off point to start looking at whether or not you should be sent for an evaluation and so we're trying to kind of break this cycle of I've seen you and now I'm going to tell you you need to go for treatment what we want you to do is to engage with a clinician who's doing something like Encompass who can evaluate you and talk you through about what's going on in your life you know how is the substances impacting your mental health like when did you first start using substances what did you notice to really create that self-awareness opportunity so 100% pediatric practices are an initial first line opportunity that doesn't really often exist as much as it should when Harris was going through his stuff I mean I would speak to the pediatrician Harris didn't look like a kid who had a mental health disorder I could talk about his anxiety he could be officially diagnosed but he was popular and social and an athlete in the life of the party because mental health disorders don't look the same for every young person he projected his behaviors out and people couldn't rationalize that he was struggling and so really being able to do that deep dive work and then not just do it but then know where to refer to because the problem is if you ask the questions and you don't know what to do then you're kind of stuck so we really want them to be empowered with the resource list and to know what to do you're saying that that list of questions is like a minute and a half to two minutes yep so do you mind sharing what are what are those questions I mean I it's literally like have you used this in the last and you know with this kind of frequency have you used this with this kind of free it's literally just the frequency and then based on those cutoffs it's very easy to determine especially if you're already screening for anxiety and depression and ADHD and all those other things how you might be somebody who is developing co-occurring disorders very good and we want pediatricians like parents to develop this non-judgmental open way of of talking to to kids and and to highlight it as important early on just as we want family members to highlight it as important so that it's a space that they can go and not feel shamed about endorsing it and so that happens through scales but it also happens by decreasing the stigma and having pediatricians open to it and then the question also asks about the involvement of family which I think is so key because that sometimes I think pediatricians struggle people with substance use disorder struggle to involve family and we know that nobody can change in isolation and so you know I think pediatricians can play an important role in sort of getting more people around the the struggling person and not sort of colluding with the hiding of it but but rather encouraging as much involvement in order for change to happen because everyone initially thinks they can change by themselves without any being one being aware but it's very hard when you're struggling with mental health and substance use to do that that's the underlying of idea about this let's talk get it out start talking about it we have two great questions we have um what do you both feel about the integration of state agency OASAS and OMH and benefits and challenges will it serve our youth and residents better and if so why and by the way could you please tell everyone tell the audience OASAS and OMH thank you so um so you've got the office of addiction services and supports which kind of covers the substance use sides of things and you have the office of mental health they are two and I do this in a slide for students and they think this is like the strangest thing they've ever seen so you've got OASAS that sits here with it's almost a billion dollars and you have OMH that sits here with it's almost a billion dollars and if I'm in a mental health program and I'm using substances they can check the box and move me out and move me into the world of substance use and that's the end of my mental health services so what we call this is a siloed system of care so funding is separate on prevention only comes down from the OASAS side there's no prevention prevention funding on the OMH side so it's like baffling because the federal government actually wrote the treatment model back in 2005 on integrated treatment for people with co-occurring disorders it sits on a shelf because every state decides what it does with its mental health and substance use dollars so a big part of my work is to actually move the agencies towards integration. We work really hard in the Mid Hudson region there is so much support from our departments of community mental health from our hospitals our agencies our providers that New York State those two agencies at the request of the governor did listening sessions fairly recently on integrating and the governor just presented his budget and truly talked about integrating OASAS and OMH so it would be you know they don't have the name yet but it would be for lack of a better way to describe it like an office of behavioral health and wellness so you would walk in you get a full comprehensive assessment you know your your combination of things would be treated in an integrated way which is the best way to do it and not like you know you've got this you're doing this or this came first you know it's like what do you what do you think's going on and it's called stages of change like when when you're ready to address those things we're here to support you and engage you so 100% fully in support of not a merger of those agencies but a true integration so that everything happens together. The spirit of this is that substance use is not something that's other but that it's a part of the mental health and medical condition and I think regulatory wise through the medical communities you know even that you go to a doctor's you should go see someone about that addiction you know we we want everything to be integrated and everything to be addressed at the same time and that showing me hope starts at the top and hopefully leads down through the system great thank you okay another another question that's come in what is the role of community in other words sports faith-based religious activities and schools in prevention identifying and supporting youth with co-occurring challenges and what we can what can people expect from them and how do we support them and educate them I guess Stephanie well I was going to let John go first I feel like I keep going first but okay so I guess this is my space so this is the kind of work that I do on empowering everybody like there is no you know I've been in churches and synagogues and school districts and athletics because the more people really understand it the easier it is to talk about so you know there are students who get cut from athletic teams because they've used substances is that really the best thing when that's probably their safest space like what can we do to like create a safe harbor to you know support student-athletes who might be struggling in other ways and so the opportunity to have comprehensive conversations to really understand the value of connecting and supporting one another and not alienating the person like you know we created our two-star logo why I had a ribbon everybody has a ribbon and I presented in New Rochelle and I listened you know there's somebody out there right now who's going to have an idea and you're going to send me an email or something and I'm going to use it I had a ribbon and the person said you know you don't want to be another ribbon in the pile like pull out something in your logo that has meaning to you and run with it so the two-stars were always on our logo because of a poem my son wrote to my daughter but it also like for the rest of the world it's like the two-stars like mental health and substance use the power of connection you know like all of those duality kind of things and then you can go and tell the story like in a really quick and easy way so you know teams wear the logo and the announcements are happening about mental health and substance use and it's homecoming and people are like was that like fun like is it cool to have this as a theme and I'm like you have to watch the bracelets going in the stands like people actively talking about this like you have breast cancer awareness games you have games for rare diseases like you're talking about things in public community settings why don't we talk about co-occurring disorders exactly the same way because the more we talk about it the easier it is to identify the more we talk about it the easier it is to know that you're not alone like Harris for all of his connections and friendships felt very alone with his struggles and so being able to say you know I have this thing it has a name you know between 50 percent of 14-year-olds have a mental health disorder with you know the age of onset 50 percent 14 75 percent by the age of 24 14 to 24 is when substance use experimentation starts like we all need to know that like why is that the big secret so I think that like when you tear the walls down it changes the game for everybody and we do a lot of our work going to churches going delivering Narcan kids doing prevention work I've struggled most in the school space though I feel schools still are very punitive around substance use and and we need to get people talking but you know the sort of quick suspensions and quick to punish you know overall the punishing narrative is still there I think a bit in schools and and certainly in society and who we put in jail and everything else and as much as we can get the spirit of we need to get people to treatment and not punish them and not expel them and distance them separate them I think is the is the key well Westchester is a happy place because like with our youth summit on March 2019 we got postponed last year obviously because of COVID and we're doing it virtually now but um we had 46 of the 48 high schools in Westchester County represented like we have encompasses going to be located in um several of the Yonkers High Schools and Neuershell High School and Porchester High School with literally clinical staff embedded at the school offering those services there's going to be unsupervised urine screening in the school like we had to get you know a permission from the superintendents they're going to the board but there really is a seismic shift in the belief that that there's help and you should keep kids within the district and you shouldn't send them somewhere else because when they come back it's really challenging for them to adjust to life back home so if we can keep them home and keep them connected that's really the best opportunity what um there's another there's another really great question how do you get to how do you get a child so this is from a parent how do you get your child to buy into the treatment plan how do you how do you get your child to think maybe there is some kind of issue um because they might say it's normal what i'm doing is normal everybody else is doing they're all drinking they're all doing whatever super hard it's hard and you know i the thing i always tell parents is the is the first thing to do is to always check your own pulse i you know i think we often are playing catch up and uh and come in hot around our kids substance use and and i think the idea is to early on set the space aside that mental health and substance use is important and that you'll be checking in often about it and want to talk about it um and and so hopefully the the conversations are in an ongoing way and and so that when as most people do they struggle at points with mental health or substance use experimenting then then it's a conversation that's that's already begun and and then when it's time to have that conversation i think the kid is fearful of punishment you know i think they're i think getting a sense of why they're using it and how you can help them and sort of just you know just keeping the conversation going and going and even if you fail the first 50 times you know highlighting to them that it that it's important that you're there and i would say and this is always the most unpopular part of it is that we have to be aware of our own substance use as parents you know i give these talks sometimes and everyone says well if my kids struggling what does this mean about my drinking and and my pot use at night and and then you know i think we do have to see we do have to model and and pay attention to our own use and as well and and so um i think all these things are important to keeping the conversation but mostly it's what we're doing here it's talking about it talking about it talking about it um and letting them know that they can come to us with without fear of punishment might if i just put this in before Stephanie before you answer why is eight or nine years old the time you're supposed to start talking we lowered it with the youth vaping epidemic that's going on because increasingly we were seeing middle schoolers vaping um or even those end development schools had their hands on jewels luckily the numbers are going down on that um but people are vaping a lot at nine not a lot but it's where it's one that you can start seeing it kids with older you start seeing an introduced at that age and so you don't ask you don't start by sort of going directly into what are you using but you can ask what they're seeing in their friend group what they've noticed you know and family members even you know by the time they're not they're pretty perceptive about what's going on and how people are dealing with emotions and and how they're dealing with their own and they're pretty savvy about this stuff and and so i think we do them a disservice if we pretend it doesn't exist and and when it does everywhere and so um you but again it's not like it's not like like the tv like sex talk where you're sitting them down and no one knows where to look it's just sort of setting the stage early that this is something that we're interested in it doesn't have to be so so dramatic and i'll just jump in on the on the eight and nine year olds first and then because this past summer i was actually invited to do a summer wellness program with the greenberg central school district and i've never worked with little ones before and we literally used our social emotional like we approached it from the social emotional side of things like you know what are the things that make a good day good what are the struggles that you're facing like all of those kind of things to really talk about like how do you use your strengths to overcome your challenges and it generated so much positive conversation but it also led to the ability to talk about you know what do some people do when they don't feel okay and you know somebody might drink and somebody might smoke and really talking about the dangers of that so i i agree it's never too soon to start talking about it and we really haven't even talked about kind of a the trauma lens in all of this as well because it's not just mental health that will lead to self-medication sometimes it's the trauma of not feeling comfortable in your own skin and not getting that validated sometimes it's sexual abuse sometimes it's it's gun violence and not feeling safe walking to school it could be food insecurity so there's so much that we make sure that we talk about so that kids see like wow i'm not okay and sometimes people use substances to just like blank that all out and how dangerous that could be but now going back to like that parent piece that you were talking about one of the things that you know i remember one of my big mouth moments like they were doing a program called hidden in plain sight where you get to see what a teenager's room looks like in all the places that they're going to hide their drugs and i literally sat there and thought okay so now you're not really coaching parents on what to do if they find anything because you're going to have the parents who come in really hot like i found this in the kids it's somebody else's and you know and all of that stuff's going to happen but that's not really getting to the the point of like why is this happening i'm concerned about this i've noticed and so i always say to parents before you speak to your child about anything have a plan know where you might turn to know who the resources are that you might go to and within compass i'm going to say and this is almost contrary to everything else less is more it's the it's the role of the intake person the person doing the assessment to help that kid figure out why they might need the program not because the parent says and if you don't go you're not getting the car like it's not supposed like it's like if your kid had cancer you wouldn't be threatening them about the cancer treatment they might be apprehensive and they might want to know why they need chemotherapy and radiation and so really empowering the young person to kind of like they do this thing called a timeline follow-back like to really look at the moments in time where the discomfort came in where the first use happened and understanding that they're not alone and that there are ways that they can work to develop the skills to manage that and most importantly the place where things often go off the rails is that as the substance use abates and the mental health starts popping they're not feeling comfortable and then they go back to what they know part of encompass is that the the prescriber in the in the agency is very engaged so you will be reassessed after a week or two and if you're not starting to feel better and the substance use is going down you're going to get an evaluation to see if there might be medication that you need it's not like you know oh we're just going to medicate you but really understanding what's going on maybe short term maybe longer term maybe something you need forever but really recognizing that this is a process and that we want to be there actively engaged in your wellness it's not like oh you're going to sit in a group talk about how you feel and then remember what life was like before substances for a kid with co-occurring disorders Harris used to say they want me to remember like I love you guys I have a great house I love my car I've never felt comfortable in my own skin my brain works a million miles an hour if they don't give me skills and tools to manage that how do they expect me not to relapse like he was that aware of what was going on yet we couldn't get him to a program that did everything the way that we hope they would great answer can you talk about can you talk about AA and co-occurring it's like it can be a complicated conversation and the historically sometimes AA had discouraged sort of medications for for mental health and substance use although I think that's changed in that they're more open to those sort of things but I think what's changed the most is that AA is not the only option anymore and that there's a menu of options for substance use and mental health issues I think you saw someone in the second trying to wrap by by the way I don't know about this is there AA for kids there is there's a very strong movement and and plenty of now transition to zoom in the setting of COVID-19 there's a lot of ways for kids to connect both with alcoholics anonymous marijuana anonymous and and a lot of folks have really benefited from it but it's just one of many options these days and and often it's used in conjunction especially if there's mental health issues with with really addressing the co-occurring mental health issues with therapy or medications as needed and so the advantages are it's a community of folks that aren't using and a community of folks who have been through similar things and and I think the discouraging of medications is as much less less common these days but it's just one of the many options so I think it can be a right fit but it's certainly not for everyone and that's what I think what we're trying to move away from so when Harris was in residential treatment part of like the discharge plan was like you had to do 90 meetings in 90 days like if it's not the right fit for you you know Harris could go to the room under the influence and so you know just being required to go is not enough for some people it's it's um it's spiritual it connects with them it resonates but there are many more options now and I always say for most people it's part of an integrated treatment plan it is not itself the treatment plan you know statistically and so that's really what we really want to highlight is that there are many pathways but you know when Harris came out of the very first rehabilitation program I was a stay-at-home mom I brought him to the psychiatrist the psychologist an intensive outpatient program 12-step meetings and the gym he relapsed in two weeks I believe that once a week in Encompass would have managed things a lot better for him because it would have allowed him that individual time with one paradigm in one setting to one pack and then you're required to come every week to your appointment with two positive pro-social non-drug using activities that you've done but they're your choice so for some kids it might be going to AA for others it might be other kinds of you know recovery programs for others it might be just going you know to the movies with somebody who doesn't use substances or participating in sports and not using drugs and so it really is it should be more self-guided that's very helpful we have someone in our audience who obviously is expert in this and and has mentioned this is in the chat a excuse me in the q&a AA doesn't take a stance on any outside issues at all international AA young people's conferences attract three to five thousand people and medical research from 2020 proved that AA participation led to better outcomes whether or not in conjunction with anything else it is free available etc it is never claimed to be a substitute for medical treatment so someone in our audience I think we're saying we're agreeing it's a wonderful treatment for so for so many folks and I think we just need a menu of options and to make sure everyone has a has a therapy that's a good fit for them yeah and thank you to whoever sent that in can I can I get to another question how do you how do you get parents to buy into the seriousness of these issues often they are so invested understandably that their kids are okay on top of that so many kids like your time at Harris the majority that they are able to just pass through this phase without any issues so how do you add in how do you how do you get parents to really focus on the seriousness it's it's the question is is a tough one because it speaks to sort of the unfairness of life a little bit in that two people could use the same substances experiment with very similar things and have very different outcomes and we know some of the risk factors for for having difficult outcomes trauma as as was mentioned trauma we often say there's a couple epidemics and addiction it would be an epidemic the youth vaping maybe benzodiazepine over prescribing but trauma is another big epidemic in addiction and so certainly trauma a family history certainly mental health struggles can can lead to the substance use sticking that being said someone could experiment and you know wind up with the fentanyl contaminated substance after not using frequently which we've seen a lot and and have a really bad outcome because of it it's unfair and it's unfair and kids often point to that hey so-and-so is using this and they're not getting into trouble what gives and and it's hard to explain I mean it's it's the reality of life that it is sort of unfair in that way that that many are okay and many aren't but we don't with our kids want to take those the risks are high still and and there are a range of ways that substance use knocks people off their tracks and often it's subtle it's not always you know so obvious and so I think we we need as a community as we're just emphasizing it again we need to keep talking about it and understand to ourselves that it's important help them recognize early on that it's important and something we're interested in to be there if our kid is the one who ends up getting stuck on it or taking risk your choices and certainly having dark hand and other resources handy if things head in that direction and then I would also say that you know if you have an existing mental health disorder if you have an emerging mental health disorder I say you know when I present I always it's almost like you have an allergy to substances like you've got enough going on in your brain as it is like what you don't want to do is introduce things that can cause additional risk for you and so if you start doing that like you're putting yourself at much higher risk then I also talk about you know that so if there's substance use disorder in your family if there's alcoholism if there are people who are struggling you need to be mindful of your potential risk just associated with that and then you know it's like so then they look at me and I'm talking about you know genetics family history trauma existing mental health disorders and they think well okay you know we're all cool like she's not talking to me I'm not part of that percentage but it's like you really are taking a risk just by experimentation you don't know if you're going to be the person who has brain changes you don't know what your what your experience is going to be you know right now with marijuana legalization again for recreational use you know young people are thinking well it's natural it's an herb it grows like everything's fine not really recognizing the relationship between my trigger you know psychosis and mental health and I talk about you know Harris had anxiety disorder and I tell him look it up boys anxiety marijuana use psychosis like that was our experience when Harris was in eighth grade like it really messed with him my daughter who had her field placement at an agency that's part of Encompass she could tell you countless people who had major mental health breaks because of marijuana use with no existing mental health disorders and so it's important to talk about it like you know sometimes parents think oh they need to practice drinking before they get to college no they're building their tolerance and they're running the risk of alcoholism if they're drinking before they go to college and before their brain is fully developed and so all of these kind of myths we tell ourselves to kind of justify certain things no oh in Europe everybody drinks young well if you actually look at the alcoholism rates in Europe they are astonishingly high and so they'd be the first to tell you that it's not a good thing and so I think that that we create these narratives to kind of justify and it's not and it's not a judgment thing it's a you know what do you need to know and how can you better tell the story of what's real and what's going on and especially like in this world that we're living in right now you know the governor will speak and it's still you know as a state we're struggling with mental health comma substance use comma trauma like no they're not they're part of the same piece of conversation and covid's only amplifying that yeah we have two we have two questions that are kind of kind of related how do parents get help and advice and where do they go for help because parents are really struggling with how to deal with this since they're the caregivers and then someone has asked um uh as a mental health professional how do how do they refer people how do they take parents and children and know where to go uh you know for a contact for help so the good news is within compass every one of our six agencies has a lead so there is a person a point of contact that you can call directly and they will respond and they will do the full assessment and know what's going on um I also am a point of contact I have everybody on a chart I know everybody's insurance I know like for example WJCS also does a lot of work with LGBTQIA plus students so the parent reaches out and they're talking about co-occurring disorders and they also say that their child has been questioning their gender identity or their transgender I will naturally gravitate towards a WJCS for a referral if they talk about you know the fact that they might have been inpatient before St. Vincent's is one of our providers so if they needed a higher level of care matching them with St. Vincent's might be a good fit and so there's enough of an array of the providers that we have that for a mental health professional it's as simple as kind of knowing that it's out there maybe attending one of our presentations to talk more about in compass and what it does and then for the parents and there are a lot of points of access you know talking to you know pediatricians it's a hit or miss if they know they know if they don't they don't school districts have gotten really solid with a lot of this because we do you know Michael Orth is on the call we do so much programming with Bosies with Southern Westchester and Putnam Northern Westchester Bosies there is not a single district in our you know if you're from Westchester there's not one school district that doesn't know about the work and isn't really well versed in it and um and even the county and we can put this like when we say the county now has a warm line from 8 a.m to 8 p.m to call about you know mental health substance use co-occurring they also have a text line so it's much easier to get connected to the resources than ever before did you say warm line a warm line like it's not a hot line like you're not calling it it's a warm line so there's they may answer but they'll call you back in like 15 minutes or so and so and you can put all this into this content that we're going to be available to everybody this is very important but thank you and Dr Avery if you're not in uh Stephanie's county then you have to invite her to to come in and create this programming and you know I mean around the country we're often saying it starts with the pediatricians and certainly having the conversation with their for adolescents and and then I think increasingly though communities are building up uh treatments that that focus on on co-occurring disorders although we're still behind you know and and I think um you guys are a shining example of how to do it for sure you know I have a I have a question I'm just going to slip in and we have another question about the legalization of pot but what's interesting is you know I was thinking about my own son I have a 22 year old I'm very fortunate and uh you know until he's until he was 18 I went in with him to the doctor and then 18 boom mom he's out you know everything is everything changes and with these laws of privacy and things has this made everything more difficult in a way or can you comment on that you know for my adolescent or my adult patients everyone wants to do it in private and no one can do it in private and and so no one can change in isolation I'm a firm believer in that and so my goal as a clinician even if they're saying I don't want to involve family members and they have that right given the privacy I always have it in my mind that there's a part of them that does and a part of them that doesn't and and you try to activate the part of them that does want to engage our family in their recovery because none of us adults kids no matter where you are in your in your life cycle can can behavioral changes the heart changes the hardest thing any of us ever do and you need help to get there and so we're encouraged I think pediatricians sometimes take it too far they're sort of very proud that they can have confidential conversations with adolescents about sex and addiction and they highlight this to the adolescent but I think they also need to highlight that they're not going to be able to do this unless we involve others that if it dies here with me then then you're not going to get the help you need and and so I do think the involving family is is is so key and it's funny Paula Riggs you know the developer in Congress she talks about that she's like you know your mom isn't in the room with you when you have sex conversation with the pediatrician and the pediatrician often doesn't ask about substance use even if they're talking about mental health so if we start getting them to talk about it then at least we're having the conversation and if they actually know what to do with it because like the goal within compass is you know so there's this program you know you kind of screens it on I'm a little concerned and we send everybody for an evaluation can I give the clinician your email your phone number can they text you and that's the initial point of entry so you know I got your name from your pediatrician you have 15 minutes to talk and then it's really the motivational interviewing and that engagement piece that's the hook because you know especially as you're heading into that 1718-19 they don't want their parents involved and so the shift is going to come when there's a better understanding like if I don't know this is potentially a problem why do I think that I need treatment for it so again like you know our stuff is like it sits everywhere you know like teens and co-occurring and here's like the information and the facts you need because if you're reading about it and you identify yourself in it and you actually have a place to go get treatment it's not so scary I mean I cannot tell you how many emails I've gotten from students so I've been treated for an anxiety disorder for the last seven years how come my mental health person never said anything about the risks of using substances like were they going to wait until it happened were they going to wait until something went terribly wrong like we really want to empower this conversation out of the gate like if you're seeing a mental health professional part of their role should be to educate you about the risks of substance use and they really don't talk about it I mean Harris saw a psychiatrist after he was significantly substance involved who said I can't prescribe for you while you're smoking marijuana if you take Benadryl to help you sleep then it's okay Benadryl is a substance of abuse so it's really important for the mental health professionals to really understand like the portion of the DSM that covers substance use that's a really important point I'm going to ask this for a friend of mine who has had a son with a substance use misuse and severe mental mental issues disorders and could not find a place that would deal with both at the same time so again where do people go and again also for parents of kids in college and with the legal the legal ramifications of not interfering I mean how does that all work and we have a bunch more questions by the way I'm sorry I'm just gonna ask I'm gonna throw that one in there you know it gets more challenging the the older they are because they you know particularly if there have been problems before and treatment hasn't been successful I often say you only get so many bites of the apples so it's really important to that your providers and know what you're getting into because programs will say that they can do just about anything but very few actually do and and it's important for you know on the mental health side I'm going to say kids start telling the mental health providers what they want to hear even if they're not feeling better and so I work with them to understand that they're a consumer that not every provider has the right evidence-based treatment protocol for you and how important it is to tell somebody if it's really not working and to go see someone else so it's part of this like understanding what's going on and the walls aren't going to tear down until there's a better conversation about the topic like colleges you know they don't there are a lot more services available than there were before but even they're not really in the co-occurring space like we do a lot of the work with the college there's a college collaborative in Westchester many that have a substance use like counseling center it's separate from the mental health center and so like there's this disconnect and so you know that's part of the advocacy work and for me that's part of my quota students who graduate because we have clubs in a lot of high schools and all the work going on in high schools who actually go to college and advocate to integrate this work and that's part of like the whole system change even that we're hoping for from a workforce development piece of what do aspiring psychologists social workers those going into the behavioral sciences really need to know about this piece of the work because it doesn't happen in isolation and it doesn't happen with a lot of collaboration. Right and I'll just add I mean the thrust of my work is improving the stigma that exists in the medical community getting more clinicians to address co-occurring disorders and the the plan in the future is hopefully at your child you wherever whatever clinician you go to mental health pediatrician internal medicine social work you know front office staff at at your college is ready to sort of address that and until we're there and unfortunately a lot of people are going to fall in the gaps and those are the gaps we see it's why less than 10 percent of people get into treatment is because one the treatment doesn't look appealing they're not being asked the right questions it feels stigmatized and so there's still a long way to go to have this this dream of ours realized that at sort of a national level and be able to you know help so many folks. We have we I'm just going to throw out two questions but I do want to say at some point maybe we can talk about policy the new Biden administration how things are going to change in that way not tonight that's important but we have two questions one is if you can supply contact information so that people can get in touch with you information about what you're both doing in the encompass program everything but one question came before from one of our someone in our audience and in early February Connecticut may vote to legalize pot this pot okay for students 21 to 24. Do you want me to tackle it I mean the the legal status of anything shouldn't change your attitudes towards it and you know that alcohol is legal doesn't mean that it's it's safe or or you know it carries its own risk maybe even more risk than than marijuana problematic alcohol use and so you know I think the worry with the the good thing about the legalization of marijuana is that there's all these low-level people are losing their lives you know being in jailed for low-level marijuana crimes and not being diverted into treatment but being imprisoned for it and that's the wrong thing we don't want that happening at the same time we don't want the perceived risk of marijuana to go down to the point that everyone's using because we know that adolescents who start using marijuana it doubles your odds of getting a marijuana use disorder almost 20 percent and we know a significant amount of folks who use marijuana especially when it slips into daily use will end up with a use disorder that doubles triples or odds of anxiety depression you know it's one of the biggest modifiable respectors for psychosis or bipolar disorder and so it carries all sorts of risks even as the legal status changes and so hopefully policy can thread the needle where it's not imprisoning people and diverting them to treatment while not making it seem like a safe harmless thing for everybody and this is I guess where the kind of a lawyer in me comes in so there's a big difference between decriminalization and legalizing for recreational use my concern and I actually testified last year when New York state was considering legalizing and they it's back on the table again there is nothing being we have not learned any lessons from tobacco from alcohol from opioids like there is no front-loaded prevention campaigns they're not working with like the department of health on really identifying early on those risk factors empowering young people pregnant women all these other you know people with mental health disorders where are the campaigns like everybody is counting the dollars that are going to magically appear from the taxes that are generated through legalization not recognizing the uptick in co-occurring disorders the need for for more treatment opportunities being able to fund those opportunities and for goodness sake like front-end the prevention stuff and really get those campaigns out there so that people are starting to hear the messaging long ahead of the legalization like that is the saddest thing for me that after we had a whole year of it being off the table it's coming up again with nothing like not one campaign associated with it and that to me is doing everybody a huge disservice because students ask me about it all the time and truth be told your brain isn't fully developed until you're 25 and you know if you've got a pre-existing mental health disorder if there's one underlying like you're running a whole bunch of extra risks and and even if you don't there's risks associated with marijuana use you know aside from laced and all the other stuff but you know the potency the impact on IQ points on motor skills you know driving under the influence and so none of that has been campaigns and prepared for ahead of us yeah well you know we have we have more questions pouring in we have a lot of questions that we're to answer but I cannot thank you enough I mean and Dan is going to come on and thank you formally but we can't thank you enough because this is incredible information and I know that people are going to go online and look at this and probably get in touch with you and we can't thank you enough for everything that you're doing really it's been fantastic and here's absolutely and thank thank you Vanessa thank you yeah thank you both for having us and for everyone who came and just to just to reiterate what we said at the top we will be sending out to everyone who registered for tonight some information some follow-up information including the link to the recording so look for that in the next couple of days it should be hitting your inboxes thank you so much thank you thanks very much Dr. Avery like Stephanie have a good night everybody have a great weekend everybody thank you thank you see you soon